physical activity and the cancer continuum: what’s the...

Physical Activity and the Cancer Continuum:

What’s the Connection?

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Goals for Today • Understand connection of physical activity to

cancer prevention and survivorship • Set the stage for engaging survivors in HEALE-

related policy and systems change strategies • Understand environmental influence on healthy

eating and active living

0 5 10 15 20 25 30 35

SmokingObesity/Poor Nutrition/Inactivity

UnknownOccupational Exposure

VirusesFamily History/Genetics

AlcoholUV and Ionizing Radiation

Prescription Drugs

Percent Attributable

Risk Factors/ Causes of Cancer in U.S.

Colditz, Wolin, Gehlert,. Sci Tranl Med, 2012

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2012 Recommendations • Individuals:

1. Maintain a healthy weight throughout life. 2. Adopt a physically active lifestyle. 3. Consume a healthy diet, with an

emphasis on plant sources. 4. If you drink alcoholic beverages, limit

consumption. • Communities:

– Work together to make it easier for people to eat better and be more active.

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Conclusion: Adherence to cancer prevention guidelines for obesity, diet, physical activity and alcohol consumption is associated with a lower risk of death from cancer, CVD, and all causes in non-smokers.

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2015 American Institute for Cancer Research Cancer Risk Awareness Survey • Reported the following

percentages of Americans who answered ‘yes’ when asked if each of the following factors has a significant effect on whether or not the average person develops cancer.

Overweight/obesity 52% Alcohol 43% Insufficient physical activity 42%

Diets low in fruits and vegetables

42%

Processed meats 38% Diets high in red meats 35%

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Obesity and Cancer Risk

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Obesity is Associated With Increased Risk of These Cancers … and Probably Others • Esophagus • Pancreas • Colon and Rectum • Breast • Endometrium

• Kidney • Thyroid • Gallbladder

Potential Mechanisms

Cancer Obesity

Adipokines/Growth Factors

Inflammation

Sex Steroids

Insulin

Increased Substrate Levels (glucose & free fatty acids)

Diabetes/other Comorbidities

Binding Proteins/Receptors

Metformin, Statins and Other Pharmacologic Agents

Adapted from Irwin et al.

Obesity* Trends, Adults 20-74 Years, by Gender and Race/Ethnicity+, US, 1976-2012

*Body mass index of 30.0 kg/m2 or greater. †Persons of Mexican origins may be of any race. Whites, blacks, and Asians are all non-Hispanic (NH). Data estimates for NH white and NH black races starting in 1999 data may not be strictly comparable with estimates for earlier years because of changes in Standards for Federal Data on Race and Ethnicity. Hispanic includes all Hispanics, not just Mexican American Hispanic persons. ‡Data for Mexican Americans are for 1982-84. §NH Asian persons and all Hispanic persons were over-sampled in the 2011-12 National Health and Nutrition Examination Survey sample, NH Asian persons for the first time. Note: Rates are age-adjusted; see Statistical Notes (p. 32) for further information. Source: National Center for Health Statistics. Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD. 2014. Complete trend data available at: <http://www.cdc.gov/nchs/hus/contents2013.htm#069> Accessed: May 20, 2014. Insert: National Health and Nutrition Examination Survey Public Use Data File, 2011-2012. National Center for Health Statistics, Centers for Disease Control and Prevention, 2014.

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Obesity Rates

0%

5%

10%

15%

20%

25%

30%

35%

1972 1976 1980 1984 1988 1992 1996 2000 2004 2008 2012

Rate

of o

besit

y

Year

USA England Spain

France

Canada

Korea

Italy

Switzerland

Mexico Australia

Obesity and Cancer • 85,000 U.S. cases per year are obesity-related.1

• Continuation of the current obesity trend will lead to about 500,000 additional cancer cases in the US by 2030.

1. Basen-Engquist K, Chang M. Curr Oncol Rep. 2011 Feb;13(1) 71-6.

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Childhood Obesity • For children and adolescents

aged 2-19 years, the prevalence of obesity has remained fairly stable at about 17% and affects about 12.7 million children and adolescents for the past decade.

Obesity* Trends, Adolescents 12-19 Years, by Gender and Race/Ethnicity+, US, 1976-2012

*Body mass index (BMI) at or above the sex- and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific BMI-for-age CDC Growth Charts. †Persons of Mexican origins may be of any race. Whites, blacks, and Asians are all non-Hispanic (NH). Data estimates for NH white and NH black races starting in 1999 data may not be strictly comparable with estimates for earlier years because of changes in Standards for Federal Data on Race and Ethnicity. Hispanic includes all Hispanics, not just Mexican American Hispanic persons. ‡Data for Mexican Americans are for 1982-84. §Estimate is considered unreliable. ¶NH Asian persons and all Hispanic persons were over-sampled in the 2011-12 National Health and Nutrition Examination Survey sample, NH Asian persons for the first time. #Number of cases <10. Relative Standard errors >30% but <40%. Note: Rates are not age-adjusted. Source: National Center for Health Statistics. Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD. 2014. Complete trend data available at: <http://www.cdc.gov/nchs/hus/contents2013.htm#070> Accessed: May 20, 2014. Insert: Ogden, CL, et al. JAMA. 2014;311(8):806-814

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Does Weight Loss Impact Cancer Risk?

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Diet and Cancer

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Consume a Healthy Diet With an Emphasis on Plant Sources

• Choose foods and beverages in amounts that help maintain a healthy weight.

• Limit consumption of processed meat and red meat.

• Eat at least 2.5 cups of vegetables and fruits each day.

• Choose whole grains in preference to refined grain products.

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Red and Processed Meats • Beef, pork, lamb • Deli meats, hot dogs, bacon, sausage

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Red and Processed Meats • 15% to 20% increased risk of cancers of the colon

and/or rectum per 100 g red meat or 50 g processed meat consumed per day. – About 3.5 oz red meat; 1.7 oz processed

• Evidence for some other cancers (esophagus, stomach, lung, pancreas, breast, prostate, stomach and endometrium) is considered limited and suggestive.

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Alcohol and Cancer

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If You Drink Alcoholic Beverages, Limit Consumption • Drink no more than one drink per day for

women or two per day for men. – One drink of alcohol =

• 12 oz. beer • 5 oz. wine • 1.5 oz. of 80-proof liquor

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Alcohol and Cancer Risk • Heavy drinking – especially combined with tobacco

use – increases risk of cancers of: – Mouth & pharynx – Larynx – Esophagus – Liver

• Even moderate drinking increases risk of breast cancer in women.

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Physical Activity and Cancer

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Adopt a Physically Active Lifestyle • Adults: Engage in at least

150 minutes of moderate intensity activity or 75 minutes of vigorous intensity activity each week – or combination - preferably spread throughout the week.

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Adopt a Physically Active Lifestyle • Children and adolescents:

Engage in at least 1 hour of moderate- or vigorous- intensity activity each day, with vigorous-intensity activity at least three days each week.

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Adopt a Physically Active Lifestyle • Limit sedentary behaviors

such as sitting, laying down, and watching television and other forms of screen-based entertainment.

Prolonged Sitting Has Been Associated With:

• Premature mortality • Cardiovascular disease and diabetes • Obesity and waist circumference • Higher systolic blood pressure • Higher fasting plasma glucose and insulin • Higher triglycerides • Lower HDL • Metabolic syndrome

• Some cancers: ovary, endometrium, breast, colon, multiple myeloma

Patel AV et.al. Am J Epid, 2010

Sitting Time and Cancer Mortality

Sitting and Site-Specific Cancer, Women

Patel AV et.al. Ca Epid Biomark Prev, 2015.

Sitting and Site-Specific Cancer, Men

Patel AV et.al. Ca Epid Biomark Prev, 2015.

Growing List of Cancers Associated with Inactivity Men Women

IARC 2002, evidence is

“Sufficient” WCRF 2007, evidence is

“Convincing or probable”

Colorectal

Colorectal Postmenopausal breast Endometrial

WCRF 2007, evidence is “Limited

Suggestive”

Pancreatic Lung Prostate

Pancreatic Lung Premenopausal breast

Harriss DJ et al 2009

Physical Activity and Colon Cancer

Lynch BM 2011

Physical Activity and Breast Cancer

Physical Activity and Endometrial Cancer

Voskuil DW et al 2007

Potential mechanisms by which physical activity reduces cancer risk

Helps to maintain healthy weight Colon/ rectum, endometrium, breast (postmenopausal), kidney May act through hormones Prostate and breast cancers Decreases circulating insulin (and glucose)

Exercise-induced increase in antitumor immune defenses

Improved antioxidant defense system

CA A Journal for Clinicians

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Why Healthy Eating and Active Living are Critical for Survivors • Cancer survivors are at greater risk for

recurrence and for developing secondary cancers due to: – The effects of treatment – Unhealthy lifestyle behaviors – Underlying genetics – Risk factors that contributed to the first cancer

Rock, et al. CA Cancer J Clin, 2012

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ACS Nutrition & Physical Activity Guidelines for Cancer Survivors

• Achieve and maintain a healthy weight.

• Engage in regular physical activity. • Achieve a dietary pattern that

emphasizes plant foods, including vegetables, fruit and whole grains.

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Post-Diagnosis Exercise Associations

• Breast cancer: – Reduction of breast cancer deaths by 34% – All cause mortality by 41% – Recurrence by 24%.

• Colon cancer: – Reduction of colon cancer death, all cause mortality and

recurrence by up to 50% • Also associated with reduced recurrence of

prostate and ovarian cancers

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Physical Activity and Cancer Survivors

• Consistent with ACSM Guidelines for Survivors • During treatment:

– Safe and feasible – Improves quality of life – reduces stress, anxiety

• Recent meta-analysis of 78 trials – Reduces fatigue

• Recent meta-analysis of 44 studies

ACSM: Precautions for Exercise Precautions for Exercise for the Cancer Survivor

Breast and Prostate and/or Bone metastases Beware of fracture risk in patients treated with hormone or angrogen deprivation therapy, or dx with osteoporosis or bone metastasis

Breast Cancer Women with UE problems secondary to txmnt should seek medical care prior to exercising training the upper body

Colon Cancer If ostomy is present physican permission recommended, excessive intra-abdominal pressure should be avoided

Stem Cell Transplant Avoid overtraining- immune system effects

Gynaecologic Cancers Beware of potential peripheral neuropathy and women with swelling in the groin, abdomen or LEs should seek medical care prior to exercise training of the lower body

Patients undergoing chemo, radiation or who have compromised immune function

Care should be taken to reduce infection in fitness centers

ACSM: Cancer Specific Considerations Considerations

Prostate Cancer Incorporate Pelvic Floor exercises

Colon Cancer Start with low resistance and progress slowly to avoid herniation

Breast Cancer Start with supervised program of at least 16 sessions and very low resistance

Stem Cell Transplant OK to exercise everyday but lighter intensity and lower progression

Bone Marrow Transplant Resistance > Aerobic

Gynaecologic Cancers If morbidly obese may require additional supervision and altered program

TABLE 3. Exercise prescription for cancer survivors.15

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CDC Surveillance of Health Behaviors Among Survivors • 28% are obese • 32% report no leisure

time activity • 15% smoke

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Compared to others of the same race and age, cancer survivors may have a … • Higher incidence of

depression. • Higher incidence of

fatigue.

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Compared to others of the same race and age, cancer survivors are at increased risk for … • Functional decline. • Adverse body composition

changes. • Osteoporosis, diabetes,

cardiovascular disease and second cancers.

• Death from other causes.

ACSM/ACS Cancer Exercise Trainer

http://certification.acsm.org/acsm-cancer-exercise-trainer

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• http://www.livestrong.org/what-we-do/our-actions/livestrong-programs/ymca/

Reducing the burden of cancer in every community.

Zip code is more important

than genetic code.

The True Determinants of Health Where we live, work, eat, play, and pray builds the foundation of good health …

… or contributes to poor health.

Building Healthier Communities • To achieve health equity, we must focus on the social and

economic factors that affect health. • This includes:

– Resources to meet daily needs

– Quality education and jobs

– Health care – Transportation

– Public safety – Social support – Technology

14,000,000+

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Healthy Eating and Active Living Environments If we are going to accelerate the impact on cancer incidence and mortality, we must work collaboratively to find strategies to address the public heath challenge of our time – the epidemic of overeating and sedentary living.

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